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DEVOTED GIVEBACK 002 TN (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 002 TN (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 002 TN (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 002 TN (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Knoxville. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 002 TN (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED GIVEBACK 002 TN (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED GIVEBACK 002 TN (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $169.20. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $605.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The prescription drug coverage for the DEVOTED GIVEBACK 002 TN (HMO) plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for up to a 3-month supply through standard pharmacies and standard mail order. For Tier 2 generic drugs, you will pay a low copay starting at $3.00 for a 1-month supply, with standard mail order offering savings on 3-month supplies at a $7.50 copay. For higher-tier medications, costs are based on coinsurance rather than set copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for both standard pharmacy and mail order services. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a 1-month supply.
Additional Benefits
The DEVOTED GIVEBACK 002 TN (HMO) plan provides comprehensive coverage with affordable cost-sharing for your essential medical needs. You will pay no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $45 copay, while inpatient hospital stays cost a $375 daily copay for days 1 through 5 and no copay for days 6 and beyond. For extra health services, the plan offers dental coverage with no copay for preventive and comprehensive care up to a $250 annual maximum. Vision benefits include a routine exam and up to $200 yearly for eyewear with no copay, while routine hearing exams require a $45 copay. Skilled nursing facility stays are also covered with no copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED GIVEBACK 002 TN (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 and beyond, subject to prior authorization. Unlimited additional days are covered for acute stays, but psychiatric stays do not cover additional days, and upgrades or non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 002 TN (HMO) covers outpatient services with no coinsurance, though prior authorization is required for most services. Outpatient hospital services have a copay of $0 to $475 ($375 per stay for observation services), outpatient substance abuse sessions require a $45 copay, and ambulatory surgical center and blood services have no copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 002 TN (HMO) covers partial hospitalization services with a $65.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 002 TN (HMO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay to $300 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED GIVEBACK 002 TN (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted within 24 hours, and urgently needed services with no copay to a $45 copay and no coinsurance. Worldwide emergency services are covered up to $25,000, with a $130 copay and no coinsurance for emergency or urgent care, and a $300 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 002 TN (HMO) covers primary care physician services with no copay and no coinsurance, while specialist and mental health services require a $45 copay and no coinsurance. Physical, speech, and occupational therapies require a $45 to $50 copay with no coinsurance, whereas chiropractic services are partially covered with routine chiropractic care not covered, and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered by DEVOTED GIVEBACK 002 TN (HMO) with no copay and no coinsurance, including annual physical exams and kidney disease education. Additional preventive services are partially covered, excluding in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED GIVEBACK 002 TN (HMO) partially covers hearing services, offering routine exams for a $45 copay and no coinsurance, plus up to two prescription hearing aids per year with a copay of $599 to $899 and no coinsurance. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision Services under the DEVOTED GIVEBACK 002 TN (HMO) plan are partially covered, featuring one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 yearly limit for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 002 TN (HMO) partially covers dental services, offering Medicare-covered dental with a $45 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED GIVEBACK 002 TN (HMO) with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 002 TN (HMO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 002 TN (HMO) partially covers medical equipment with no copays, featuring 20% to 50% coinsurance for durable medical equipment, no coinsurance to 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 50% coinsurance for diabetic supplies. Diabetic therapeutic shoes and inserts are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 002 TN (HMO) with prior authorization required, featuring no coinsurance and a $0 to $95 copay for diagnostic tests, and no copay for lab services or outpatient X-rays. Diagnostic radiological services have a copay starting at $0, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 002 TN (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the DEVOTED GIVEBACK 002 TN (HMO) plan require prior authorization and feature no copay and no coinsurance, though only some services are covered. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 002 TN (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day inpatient hospital stay required. Patients pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 002 TN (HMO) partially covers other services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Other supplemental benefits, such as acupuncture, over-the-counter (OTC) items, meal benefits, and dual-eligible SNP services, are not covered.
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